What are the Different Parts of a Vermont Health Insurance Policy?

When you buy a health insurance policy, you will usually get several different documents, all of which work together.

If you are one of the many Vermonters who get insurance through an employer, you will receive:

• A Certificate of Coverage, which describes in detail the kind of coverage and benefits you have, including an outline (or Schedule) of Coverage, which tells you about specific conditions that apply to your group policy, like deductibles, co-payments and limits on certain types of services, and,
• A member Handbook: This gives you a more general description of how your plan works, what is covered and not covered, and what you must do to get health care.

If you buy your insurance directly from the insurer you will receive:

• A Health Insurance Policy, which describes in detail the kind of coverage and benefits you have and,
• An outline (or Schedule) of Coverage, which explains your deductibles, co-payments, co-insurance and limits on certain services.

The Insurance Contract

The insurance contract is the binding agreement between an insurance company and your employer or you. If your employer purchases group insurance, the insurance company must provide a certificate of coverage that summarizes the contract to each subscriber. You have the right to see the contract itself at your employer's personnel office. If you buy your own insurance, you will get a copy of the your insurance policy directly from the company.

In looking at your contract and accompanying materials, you should pay special attention to the following sections:

Definitions. This section explains, as precisely as possible, the meanings intended for terms used in the policy. These definitions are key to understanding the extent of coverage your policy provides.

Covered services. The policy may describe the covered services in one section, or may break them into several sections, such as "inpatient care," "outpatient care" or "medical services," "home care," and "emergency care." These sections explain exactly what services are covered.

Exclusions. This section details what is not covered by your policy under any circumstances.

Endorsements or amendments. An endorsement or amendment to your policy can add, remove or change the standard coverage described in the contract. Sometimes amendments or endorsements appear in the contract you receive, and sometimes the insurance company sends them to you separately. For example, if the law is changed to require coverage of a certain type of disease that is not covered by a policy, your insurer will send you an endorsement or amendment that becomes part of the policy you already have. Endorsements are subject to the other terms and conditions of your contract, like co-payments or deductibles and coinsurance.

Riders. A rider usually includes one or more new benefits that can be bought, at additional cost, to expand the services covered under your health insurance contract. An example of a rider includes coverage for prescription drugs, if they are not covered in your standard policy. Occasionally, a rider will reduce coverage, which may also reduce your premium.

Outline (or schedule) of coverage. This document or section of your contract details any particular conditions that apply to your coverage. It also explains how much you will have to pay for services. For example, it will tell you the amount of your deductible(s) or co-payment(s) and any differences in payment for in-network and out-of-network services.

Your rights and obligations. The contract will usually include sections explaining the policyholder's obligation to pay premiums to keep the policy in force. It will also tell you under what circumstances the contract may be canceled, and what rights you may have at that time.

What Kinds of Services are Usually Covered?

Your health insurance policy will give you lots of information about what services your insurance company will cover. In most cases, the insurer will only cover medically necessary services, which means that the care must be consistent with generally accepted medical practices as recognized by other health care providers in the same or similar medical specialty to diagnose, treat or manage specific medical conditions. The following is a summary of the coverage you should expect if you have a comprehensive health insurance policy. Please check your own policy for variations and further details.

• Inpatient care. This usually includes stays in a general hospital for acute care. Most policies do not pay for private-duty nurses, private rooms or non-medical items (such as television rentals).
• Medical services. These generally include the services of physicians and other health care providers (including specialists) for routine office visits, lab services, diagnostic procedures like x-rays and CT scans, maternity care, outpatient surgery and emergency care.
• Mental health and substance abuse services. These services must be provided with the same types of deductibles or co-payments that are applied to other health care services. A health insurance policy cannot limit the number of visits you get for these services, or cap the amount of reimbursement for those services, unless the same visit limits or caps apply to all health services provided under the contract. Alcoholism is covered under substance abuse treatment.
• Certain types of chemotherapy treatments. Medically necessary growth cell stimulating factor injections that are part of a prescribed chemotherapy regimen must be covered.
• Coverage of disabled children, regardless of age, who are unmarried, cannot care for themselves and are dependent on the insured person.
• Coverage for newborn children for the first 31 days after their birth. Newborn children are automatically covered under your policy for the first 31 days of the newborn's life if you already have coverage for at least two people covered on your policy at the time of the newborn's birth. You must notify your insurance company within those 31 days, and pay any additional premiums due, in order to keep the coverage in place after those 31 days. If you have single coverage (that is, coverage for yourself only) and have a child, you must notify your insurance company and pay the premium necessary to add your child as a dependent within 31 days of the child's birth. If you do so, the coverage is retroactive to the day the baby was born.
• Diabetes education and treatment. Treatment for diabetes must be covered subject to the same contract limits as other services provided under the health insurance contract (that is, subject to the same deductible, co-payments or coinsurance). The diabetes law applies to both insulin dependent and non-insulin dependent diabetics. In addition to requiring coverage for insulin, this law requires insurance companies to pay for diabetes-related equipment, supplies, education, training and nutrition therapy.
• Mammograms for women. Women aged 50 and older are covered for a mammogram annually, or more often when recommended by the woman's health care provider. For women under age 50, mammograms are covered upon recommendation of their health care provider. While your policy is required to cover annual mammograms, this benefit may be subject to a deductible or co-payment.
• Mternity care. Policies must cover the costs associated with maternity care. Maternity stays and newborn discharge guidelines are set by federal law.
• Payment for PKu (an inherited metabolic disease) supplies and medication. Plans must pay for foods that are medically necessary for treating inherited metabolic disease at a minimum level of $2,500 per person per year.
• Craniofacial disorders. Plans must pay for medically necessary treatment of specific musculoskeletal disorders, including temporomandibular joint syndrome (TMJ).

Remember: Contracts are usually written in a very formal, legal way. If you have questions about whether a particular type of service is covered, you should call your health insurer's member services department for more information. You can also call the Vermont Health Care Administration toll-free for Consumer Assistance at 800-631-7788.

Your Responsibilities

You have certain responsibilities to make sure you get the most from your insurance coverage. These include the following:

• You must fill out the health insurance application fully and accurately.
• You must pay the premiums as they become due if they are not paid by your employer.
• You must follow your plan's requirements for getting care. For example, if you are covered by an indemnity plan, this means notifying the company of a claim within the time period required by the policy. If you are covered by an HMO, PPO or POS plan, this usually means getting care from your primary care provider or getting referrals or prior authorizations before seeing specialists.

Claims Processing Tips

If you are insured through an HMO, you will rarely, if ever, see the actual bill for your health care services. Once you have paid your visit fee or co-payment at the doctor's office or hospital, the rest of the billing is taken care of between the provider and the HMO.

Similarly, if you are insured through a PPOs or POS, you will not see a bill for your health care services if you use the plan's network providers, except for visit fees or co-payments at a doctor's office or hospital. The remainder of the bill will be taken care of between the provider and the plan. However, if you receive care from a provider who is not in the plan's network, you may have to submit a claim for those services directly to the insurer for payment.

Insurance companies pay claims for indemnity-type policies differently. Most health care providers will submit claim forms directly to your insurance company for payment. You and your provider(s) will get an Explanation of Benefits (EOB) from your insurance company after the claim is processed.

However, some providers may want to be paid in full by you, and leave you with the responsibility for getting paid from your insurance company. In this case, you will have to submit a claim form, with your copy of the hospital or physician bills, together with any necessary supporting documentation, to the insurance company. Supporting documentation can include the doctor's office notes, lab reports, or operative reports, depending upon what service was provided. Once the insurance company receives the claim form, it reviews the claim against your policy to determine if benefits can be provided. The insurance company then sends you, the insured, an "EOB" ("Explanation of Benefits") that tells you how your claim was processed and, will send you a check, if you had paid the provider.

It is very important for you to look at your EOBs and any doctors' bills you get. You should make sure the services listed on an EOB match the services you received. If a service is not covered, or is only partially covered (if, for example, you have to pay 20% coinsurance), the EOB will help you understand what you will be billed by the doctor or hospital after the insurance company pays its share.